Fire Drills Not Conducted at Unexpected Times
Penalty
Summary
The facility failed to conduct fire drills at unexpected times as required by the 2012 NFPA 101 standards. During a Life Safety Code Survey, a review of the facility's fire drill logs for the past 12 months revealed that the drills were consistently held at similar times across all shifts. Specifically, for the morning shift (7:30 AM - 3:30 PM), three out of four drills were conducted between 10:14 AM and 11:00 AM. For the evening shift (3:30 PM - 11:30 PM), three out of four drills occurred between 5:20 PM and 5:40 PM. Similarly, for the night shift (11:30 PM - 7:30 AM), three out of four drills were conducted between 6:15 AM and 6:25 AM. The Senior Director of Operations acknowledged the issue and mentioned the intention to spread the drills more evenly throughout each shift. The Engineering Manager noted that the timing was chosen to avoid waking residents during evening and night shifts.
Plan Of Correction
Plan of Correction: Approved December 30, 2024 Plan of Correction for affected areas: The Director of Maintenance will complete the fire drills at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency. All fire drills will be a minimum of 1 hour apart on each shift and not duplicated in the same 12-month period. Fire drills conducted between 9:00 p.m. and 6:00 a.m. (2100 hours and 0600 hours), a coded announcement shall be permitted to be used instead of audible alarms. Plan of Correction to identify other areas potentially affected: The facility acknowledges that all residents have the potential to be affected by this practice. All Fire Drills are conducted by the Director of Maintenance. Plan of Correction for system measures to prevent reoccurrence: The Director of Maintenance developed a Fire Drill spreadsheet to document varied times and conditions of each drill monthly to maintain compliance. The Senior Director of Operations will review the spreadsheet monthly for compliance and will utilize an audit tool to document the findings and report the audit findings to the Quality Assurance/Quality Improvement Committee monthly for a period of six (6) months. Plan of Correction for monitoring corrective actions: The Director of Maintenance or Designee will review monthly audits for any cases of non-compliance. The Senior Director of Operations or Designee will report the result of the audits to the Quality Assurance/Quality Improvement Committee on a monthly basis for 6 months, as well as correction plan if warranted. Responsibility: Director of Operations Compliance Date: January 27, 2025